Exam 4 retake

The registered nurse taking shift report learns that an assigned client is blind. How will the nurse best communicate with this client? Select all that apply. a. Speak directly to them using a normal tone of voice b. State her name and role immediately after entering the client's room c. Introduce herself in a firm, loud voice at the doorway of the room d. Provide instructions in simple, clear terms e. Lightly touch the client's arm and then introduce herself

A, B

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding will the nurse expect for a client with this diagnosis? a. Neck flexion produces flexion of knees and hips b. Pain upon ankle dorsiflexion of the foot c. Inability to stand with eyes closed and arms extended without swaying d. Numbness and tingling in the lower extremities

a

Which of the following nursing interventions will most likely facilitate effective communication with a hearing-impaired client? Select all that apply. a. Raise the voice to project sound at a higher frequency b. Reduce environmental noise and distractions before communicating c. Stand directly in front of the client to facilitate lip reading d. Ask the client to repeat what was said in order to evaluate understanding e. Repeat the question or rephrase it to the client

b, d, e

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspects of the client's current health status is most likely to have precipitated this event? Select all that apply. a. The client was not repositioned during the night shift. b. The client has developed a pressure ulcer. c. The client received a blood transfusion. d. The client's analgesia regimen was recently changed. e. The client's urinary catheter became occluded.

b, e

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply? a. "Are you exposed to any toxins or chemicals at work?" b. "When was the last time you were hospitalized?" c. "What medications are you currently taking?" d. "Does anyone else in your family struggle with headaches?" e. "How would you describe your ability to cope with stress?"

a, c, d, e

A client presents to the ED reporting a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The client mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the client's diagnosis will be? a. Ménière disease b. Labyrinthitis c. Ototoxicity d. Ossiculitis

b

A neurologic flow chart is often used to document the care of a client with a traumatic brain injury. At what point in the client's care will the nurse begin to use a neurologic flow chart? a. When the client's condition begins to deteriorate b. As soon as the initial assessment is made c. At the beginning of each shift d. When there is a clinically significant change in the client's condition

b

The nurse is assessing a client with increased intracranial pressure (ICP). What assessment will the nurse prioritize? a. Pays attention to grooming and appearance b. Obeys commands with appropriate motor responses c. Registers normal body temperature d. Copes with sensory deprivation

b

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What will the nurse be correct in teaching the client to avoid? a. Drinking large amounts of fluids b. Washing his face c. Using artificial tears d. Exposing skin to sunlight

b

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? a. Administering an antifibrinolytic agent b. Placing the client on a fluid restriction as prescribed c. Applying thigh-high elastic stockings d. Assisting the client with passive range-of-motion (PROM) exercises

c

Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear will be reported by the nurse immediately? a. The malleus can be visualized during otoscopic examination. b. Tenderness is reported by the client when the mastoid area is palpated. c. Clear, watery fluid is draining from the client's ear. d. The tympanic membrane is pearly gray.

c

During discharge teaching the nurse realizes that the client is not able to read medication bottles accurately and has not been taking her medications consistently at home. How will the nurse intervene? a. Ask the social worker to investigate community support agencies b. Ask the social worker to investigate alternative housing arrangements c. Encourage the client to explore surgical corrections for the vision problem d. Arrange for referral to a rehabilitation facility for vision training

A

A client is scheduled for MRI has arrived at the radiology department. the nurse who prepares the client for the MRI should prioritize what action? A. Withholding stimulants 24 to 48 hrs prior B. Removing all metal containing objects C. Initiate an IV for administration of contrast D. Instruct the client to Coid prior to MRI

B

A client is exploring treatment options after being diagnosed with cataracts that affect her vision. What treatment is most likely to be used in this client's care? a. Corticosteroid eye drops b. Eyeglasses or magnifying lenses c. Antioxidant supplements, vitamin C and E, beta-carotene, and selenium d. Surgical intervention

D

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care will address what characteristic manifestation of this disease? a. Facial paralysis. b. Diplopia c. Tinnitus d. Pain at the base of the tongue

a

The nurse is caring for a client with an altered level of conciousness and regularly assesses for potential complications. The nurse will assess for which complications? Select all that apply. a. Pneumonia b. Contractures c. Hemorrhage d. Pressure ulcers e. Venous thromboembolism

a, b ,d, e

An older adult client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client and family, the nurse will provide teaching in which areas? Select all that apply. a. How to use a sign board b. Transfer techniques c. Information about impulse control d. Nutrition support e. Time adjustment to complete activities

a, b, d, e

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? a. Temporal lobe b. Inferior-posterior frontal areas c. Parietal--occipital area d. Posterior frontal area

c

A 72-year-old man has been brought to his primary provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle will underlie the nurse's assessment and management of this client? a. Thorough assessment is necessary because changes in cognition are always considered to be pathologic. b. Lapses in memory in older adults are considered benign unless they have negative consequences. c. Gradual increases in confusion accompany the aging process. d. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic.

a

A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client will be kept in a prone position until otherwise ordered. What will the nurse do? a. Follow the order because this position will help keep the retinal repair intact b. Reposition the client after the first dressing change c. Call the physician and ask for the order to be confirmed d. Instruct the client to maintain this position to prevent bleeding

a

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse will teach the family that these responses are typically a result of what cause? a. Frustration around changes in function and communication b. Temporary changes in metabolism c. Changes in brain activity during sleep and wakefulness d. Unmet physiologic needs

a

A middle-aged woman has sought care from her primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What signs or symptoms are most likely to have prompted the woman to seek care? Select all that apply. a. Depression b. Personality changes c. Cognitive declines d. Contractures e. Difficulty in coordination

a, e

A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse will be aware that the effects of the tumor will primarily depend on what variable? a. The client's pre-existing health status b. Whether the tumor is primary or the result of metastasis c. The specific hormones secreted by the tumor d. Whether the tumor utilizes aerobic or anaerobic respiration

c

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What will the nurse suspect? a. Hypertensive emergency b. Hypovolemia c. Spinal shock. d. Epidural hemorrhage

c

A hearing-impaired client is scheduled to have an MRI. What will be important for the nurse to remember when caring for this client? a. The nurse should interact with the client like any other client. b. Lip reading will be the method of communication that is necessary. c. Client is likely unable to hear the nurse during test. d. A person adept in sign language must be present during test.

c

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? a. To decrease cerebral arterial pressure b. To prevent aspiration of stomach contents c. To avoid impeding venous outflow d. To prevent flexion contractures

c

While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? a. Page the health care provider and report this sign of infection b. Reinforce the dressing and reassess in 1 to 2 hours c. Inform the surgeon of the possibility of a dural leak d. Reposition the client to prevent further hemorrhage

c

A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane will be what color in a healthy ear? a. Pink b. Yellowish-white c. Bluish-white d. Gray

d

A child goes to the school nurse and reports being unable to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? a. Rinne test b. Weber test c. Audiometry d. Whisper test

d

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? a. Inform the nurse manager b. Sit with the client for a few minutes c. Administer an analgesic d. Call the health care provider immediately

d

A client has been diagnosed with serous otitis media for the third time in the past year. How should the nurse bestinterpret this client's health status? a. Blood cultures should be drawn to rule out a systemic infection. b. For some clients, these recurrent infections constitute an age-related physiologic change. c. The client would benefit from a temporary mobility restriction to facilitate healing. d. The client needs to be assessed for nasopharyngeal cancer.

d

A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? a. Explain that each of the items on the tray is clearly separated b. Ask the client to describe the location of items before confirming their location c. Describe the location of items from the bottom of the plate to the top d. Explain the location of items using clock cues

d

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes decreased in older adults, what must be used with caution? a. Whirlpool baths b. Anti-inflammatory medications c. Analgesics d. Hot or cold packs

d

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? a. Loss of vision, change in mental status, and hyperthermia b. Loss of vision, headache, and tachycardia c. Loss of hearing, increased sodium retention, and hypertension d. Loss of hearing, tinnitus, and vertigo

d

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How will the nurse best position the client? a. Position the client supine b. Maintain bed in Trendelenburg position c. Position client in prone position d. Maintain head of bed (HOB) elevated at 30 to 45 degrees

d

The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk will the nurse prioritize in this client's care? a. Risk for unilateral neglect b. Risk for ineffective health maintenance c. Risk for disturbed sensory perception d. Risk for falls

d

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? a. Providing appropriate pain control b. Inserting a nasogastric (NG) tube as prescribed c. Maintaining accurate records of intake and output d. Maintaining a patent airway

d

A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What will the nurse teach this client? a. The hearing loss will likely resolve with time after the drug is discontinued. b. The client's tinnitus is likely multifactorial, and not directly related to aspirin use. c. The client's tinnitus will abate as tolerance to aspirin develops. d. The client's hearing loss and tinnitus are irreversible at this point.

a

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? a. To remove atherosclerotic plaques blocking cerebral flow b. To determine the cause of the TIA c. To decrease cerebral edema d. To prevent seizure activity that is common following a TIA

a

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? a. Evidence of hemorrhagic stroke b. Blood pressure of ≥180/110 mm Hg c. Previous thrombolytic therapy within the past 12 months d. Evidence of stroke evolution

a

A client is having a "fight or flight response" after receiving bad news about his prognosis. What affect will this have on the client's sympathetic nervous system? a. Increase in the secretion of sweat b. Constriction of blood vessels in the heart muscle c. Constriction of pupils d. Constriction of bronchioles

a

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? a. To avoid impeding venous outflow b. To prevent aspiration of stomach contents c. To decrease cerebral arterial pressure d. To prevent flexion contractures

a

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? a. Bruising over the mastoid b. Periorbital edema c. Unilateral facial numbness d. Epistaxis

a

The client in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurse's most appropriate action? a. Position the client prone b. Position the client left side-lying c. Position the client supine with the head of bed flat d. Administer acetaminophen as prescribed

a

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What dysrhythmia does this client most likely have? a. Atrial fibrillation b. Bundle branch block c. Supraventricular tachycardia d. Ventricular tachycardia

a

The nurse is caring for a client who is postoperative following a craniotomy. What assessment will the nurse prioritize? a. Monitor serum electrolytes b. Change the client's position as indicated c. Maintain NPO status d. Monitor arterial blood gas (ABG) values

a

A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the client? a. The client should monitor her IOP closely for the next several weeks. b. The client should do further research on the herbal remedy. c. The client should report any adverse effects to her pharmacist. d. The client should discuss this new remedy with her ophthalmologist promptly.

d

After a subarachnoid hemorrhage, the client's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? a. Facilitate testing for hypothalamic dysfunction b. Prepare the client for thrombolytic therapy as prescribed c. Administer a bolus of normal saline as prescribed d. Prepare to administer 3% NaCl by IV as prescribed

d

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? a. Prepare the client for craniotomy b. Position the client in the high Fowler position as tolerated c. Administer osmotic diuretics as prescribed d. Provide interventions to increase cerebral perfusion pressure (CPP)

d

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? a. Shortness of breath b. Generalized pain c. Tonic-clonic seizures d. Alteration in level of consciousness (LOC)

d

A client with suspected Parkinson disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor? a. When the client is preparing their meal tray to eat b. When the client is resting c. When the client is participating in occupational therapy d. When the client is ambulating

b

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations will the nurse expect in this client? a. Respiratory distress and projectile vomiting b. Bradycardia and hypertension c. Third-spacing and hyperthermia d. Tachycardia and agitation

b

A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding? a. "I need to call the doctor if I see flashing lights." b. "I need to call the doctor if I get a scratchy feeling." c. "I need to call the doctor if I get nauseated." d. "I need to call the doctor if I have a light morning discharge."

a

A client presents at the ED after receiving a chemical burn to the eye. What will be the nurse's initial intervention for this client? a. Generously flush the affected eye with normal saline or water b. Apply direct pressure to the affected eye c. Apply a patch to the affected eye d. Generously flush the affected eye with a dilute antibiotic solution

a

Order: Phenobarbital sodium 100 mg IM Drug available: Phenobarbital sodium 125 mg/2 mL How many mLs should the patient receive? _ mL Order: Phenobarbital sodium 100 mg IM Drug available: Phenobarbital sodium 125 mg/2 mL How many mLs should the patient receive?

1.6 mL

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What will this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply. a. Diabetic retinopathy b. Macular degeneration c. Trauma d. Glaucoma e. Cytomegalovirus

a, b, d

A client with a spinal cord injury has experienced several hypotensive episodes. How will the nurse best address the client's risk for orthostatic hypotension? a. Allow the client to initiate repositioning b. Administer an IV bolus of normal saline prior to repositioning c. Monitor the client's BP before and during position changes d. Maintain bed rest until normal BP regulation returns

c

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse will be correct in suspecting the presence of what complication? a. Catheter occlusion b. Encephalitis c. CSF leak d. Meningitis

d

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse will know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply. a. Becoming a burden on the family b. Possible nursing home placement c. Pain associated with physical therapy d. Increasing disability e. Loss of appetite

a, b, d

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse will gauge the client's LOC on the results of what diagnostic tool? a. Glasgow Coma scale b. Mental status examination c. Monro-Kellie hypothesis d. Cranial nerve function

a

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? a. Vigilant monitoring of fluid balance b. Monitoring of the client's airway for patency c. Serial arterial blood gases (ABGs) d. Continuous BP monitoring

a

A client is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière disease. What question is it most important for the nurse to ask the client in preparation for this test? a. Do you currently take any tranquilizers or stimulants on a regular basis? b. Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? c. Do you have a history of either high or low blood pressure? d. Do you have a history of falls or problems with loss of balance?

a

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what will the nurse's primary assessment focus? a. Cardiac and respiratory status b. Pain c. Seizure activity d. Fluid and electrolyte balance

a

A client who was diagnosed with Parkinson disease several months ago recently began treatment with levodopa-carbidopa. The client and his family are excited that he has experienced significant symptom relief. The nurse will be aware of what implication of the client's medication regimen? a. Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment. b. Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. c. The client's temporary improvement in status is likely unrelated to levodopa-carbidopa. d. The client is in a "honeymoon period" when adverse effects of levodopa-carbidopa are not yet evident.

a

The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How will the nurse proceed with assessing the client's level of consciousness (LOC)? a. Assess the client's eye opening and response to stimuli b. Facilitate diagnostic testing in an effort to obtain objective data c. Assess the client's vital signs and correlate these with the client's baselines d. Document that the client currently lacks a level of consciousness

a

The nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-administer these medications safely and effectively? a. Ask the client to demonstrate the instillation of her medications b. Assess the client's functional status c. Assess the client for any previous inability to self-manage medications d. Determine whether the client can accurately describe the appropriate method of administering her medications

a

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse will anticipate the use of what medications? a. Cholinergics b. Antibiotics c. Potassium-sparing diuretics d. Loop diuretics

a

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what will be the nurse's most appropriate action? a. Prepare for interventions to increase the client's BP. b. Prepare an ice bath to lower core body temperature c. Place the client in the Trendelenburg position d. Prepare to transfuse packed red blood cells

a

A client has lost most of her vision as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action are most appropriate? Select all that apply. a. Assess and promote the client's coping skills during interactions with the client b. Allow the client to express her feelings related to the vision loss c. Promote the client's hope for recovery d. Emphasize that her lifestyle will be unchanged once she adapts to her vision loss e. Encourage the client to focus on her use of her other senses

a, b

A family member of a client diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this client and family receive from this organization? Select all that apply. a. Information about this disease b. Referrals c. Public education d. Individual assessments e. Appraisals of research studies

a, b, c

A client with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care will the home health nurse focus? Select all that apply. a. Pain control b. Management of treatment complications c. Administration of treatments. d. Interpretation of diagnostic tests e. Assistance with self-care

a, b, c, e

A patient had cataract surgery. What instructions would the nurse provide? Select all that apply. a. Call the doctor for increased pain b. Do not lift more than 10 lbs c. Avoid constipation or straining d. Sexual intercourse is allowed e. Do not bend over from the waist

a, b, c, e

The advanced practice nurse is attempting to examine the client's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the client's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing interventions are most important to minimize nausea and vertigo during the procedure? Select all that apply. a. Maintain the irrigation fluid at a warm temperature b. Follow the procedure with insertion of a cerumen curette to extract missed ear wax c. Instill short, sharp bursts of fluid into the ear canal d. Maintain the irrigation using gentle pressure e. Have the client stand during the procedure

a, d

The nurse caring for a client in ICU diagnosed with Guillain--Barré syndrome will prioritize monitoring for what potential complications? Select all that apply. a. Autonomic dysfunction b. Cognitive deficits c. Hemorrhage d. Respiratory failure e. Impaired skin integrity

a, d

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in client teaching? Select all that apply. a. Inspect the lower extremities for skin breakdown b. Dietary modifications are likely necessary. c. Immediate family members should be screened for the disease. d. Assistive devices may be needed to reduce the risk of falls. e. Footwear needs to be accurately sized.

a, d, e

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse will be cognizant of what contraindications for thrombolytic therapy? Select all that apply. a. Current anticoagulation therapy b. Sudden symptom onset c. INR above 1.0 d. Symptom onset greater than 3 hours prior to admission e. Recent intracranial pathology

a, d, e

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. a. MRI b. Cranial radiography c. Electromyelography (EMG) d. Transcranial Doppler flow study e. Cerebral angiography

a, d, e

The nurse is providing community education regarding strokes. Which information will be included? Select all that apply. a. A stroke is caused by interruption of blood flow to the brain b. All strokes are preventable if you take care of yourself, eat right, control you blood pressure and reduce your stress. c. A stroke usually occurs simultaneously with myocardial infarction. d. Rapid recognition of stroke symptoms can help decrease poor outcomes. e. A stroke causes neurological deficits.

a, d, e

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What will the nurse identify as prominent risk factors for SCI? Select all that apply a. Alcohol or drug use. b. African-American race c. Frequent travel d. Male gender e. Young age

a, d, e

A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? Select all that apply. a. Avoid sharing face cloths, towels and eye drops b. The importance of compliance with antibiotic therapy c. Signs and symptoms of complications, such as meningitis and septicemia d. The likely need for surgery to prevent scarring of the conjunctiva e. Handwashing can prevent the spread of the disease to others

a, e

A client is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care will the nurse describe to the client? Select all that apply. a. Application of topical antibiotic ointment b. Administration of loop diuretics to prevent orbital edema c. Fluid restriction to prevent orbital edema d. Maintenance of a supine position for the first 48 hours postoperative e. Use of an ocular pressure dressing

a, e

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? a. Understand that the surgery may have been unsuccessful b. Recognize that this may represent the peak of postsurgical cerebral edema c. Alert the surgeon to the possibility of an intracranial hemorrhage d. Recognize the need to refer the client to the palliative care team

b

A client with Parkinson disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs will be met by what method? a. Minced foods and a fluid restriction b. Semisolid food with thick liquids c. Provision of a low-residue diet d. Total parenteral nutrition (TPN)

b

The nurse is caring for a client who is in status epilepticus. What medication will the nurse anticipated administering to halt the seizure immediately? a. Intravenous phenobarbital b. Intravenous diazepam c. Oral lorazepam d. Oral phenytoin

b

The nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result will indicate the presence of a sensorineural loss? a. The sound is heard longer in the ear in which hearing is better. b. The sound is heard better in the ear in which hearing is better. c. The sound is heard equally in both ears. d. The sound is heard better in the ear in which hearing is poorer.

b

An elderly client was admitted to the Medical-Surgial unit after a fall. What vital signs indicate Cushing's Triad? Select all that apply. a. Morning vital signs include respiratory rate of 10 Afternoon vital signs include respiratory rate of 15 b. Morning vital signs include heart rate of 62 Afternoon vital signs include heart rate of 52 c. Morning vital signs include blood pressure of 110/70 Afternoon vital signs include blood pressure of 130/50 d. Morning vital signs include heart rate of 62 Afternoon vital signs include heart rate of 70 e. Morning vital signs include blood pressure of 110/70 Afternoon vital signs include blood pressure of 110/72

b, c

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions will the nurse perform? Select all that apply. a. Obtain a blood type and cross-match b. Monitor pain levels and administer analgesics c. Perform frequent neurologic assessments d. Place the client in positive pressure isolation e. Administer antipyretics as prescribed

b, c, e

A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what? Select all that apply. a. A "scratchy" feeling in the eye b. Increase in redness of the eye c. Flashing lights d. Slight morning discharge from the eye e. A new floater in vision

b, c, e

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? Select all that apply. a. Hyperpatellar reflex b. Photophobia c. Sluggish pupil reaction d. Positive Kernig sign e. Negative Brudzinski sign

b, d

A patient is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the patient indicate a good understanding of home management of this condition? Select all that apply. a. "When the infection is gone, I can use my contacts again." b. "Eye irrigations should be done with warm saline or water." c. "As long as I don't wipe my eyes, I can share my towel." d. "I will throw away all my eye makeup when I get home." e. "I won't touch the tip of the eyedrop bottle to my eye."

b, d, e

The nurse is caring for a client with a brain tumor who is experiencing symptoms due to compression and infiltration of normal tissue. The pathophysiologic changes that result can cause what manifestations? Select all that apply. a. Intracranial hemorrhage b. Altered pituitary function c. Seizure activity d. Increased ICP e. Infection of cerebrospinal fluid

b,c,d

A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client complains of pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position? a. In the reverse Trendelenburg position b. In the Trendelenburg position c. In a flat side-lying position d. In the high Fowler position

c

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse will expect to administer what priority medication? a. Spirolactone b. Hydrochlorothiazide c. Mannitol d. Furosemide

c

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? a. Insertion of an intracranial monitoring device b. Administration of anticoagulant therapy c. Making openings in the skull d. Treatment with antihypertensives

c

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention will be most appropriate for this client? a. Passive range-of-motion exercises to prevent contracture b. Supine positioning c. Absolute bed rest in a quiet, nonstimulating environment d. Early initiation of physical therapy

c

Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse will be correct in implementing what priority nursing action? a. Stabilize the head in a lateral position b. Complete the pin site care to decrease risk of infection c. Notify the neurosurgeon of the occurrence. d. Reattach the pin to prevent further head trauma

c

The nurse in an extended care facility is planning the daily activities of a client with postpolio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time? a. Immediately after meals b. Before bedtime c. In the morning d. In the early evening

c

The nurse is admitting a 55-year-old male client diagnosed with a retinal detachment in his left eye. While assessing this client, what characteristic symptom will the nurse expect to find? a. Colored halos around lights b. Sudden eye pain c. Flashing lights in the visual field d. Loss of color vision

c

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? a. Generalized pain b. Shortness of breath c. Alteration in level of consciousness (LOC) d. Tonic-clonic seizures

c

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? a. Electrolyte restriction b. Transfusion of fresh frozen plasma (FFP) c. Fluid restriction d. Transfusion of platelets

c

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What dysrhythmia does this client most likely have? a. Supraventricular tachycardia b. Ventricular tachycardia c. Atrial fibrillation d. Bundle branch block

c

The nurse is planning the care of a client with Parkinson disease. The nurse will be aware that treatment will focus on what pathophysiologic phenomenon? a. Delayed reuptake of serotonin b. Premature degradation of acetylcholine c. Decreased availability of dopamine d. Insufficient synthesis of epinephrine

c

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What will be the nurse's best answer? a. "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." b. "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." c. "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel. d. "The sudden, severe headache increases muscle tone and can cause further nerve damage."

c

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? a. Educate clients about the risks associated with prolonged exposure to environmental noise b. Ensure that clients understand the differences between sensory hearing loss and conductive hearing loss c. Be aware of clients' medication regimens and collaborate with other professionals accordingly d. Educate clients about expected age-related changes in hearing perception

c

While completing a health history on a client who has recently experienced a seizure, the nurse will assess for what characteristic associated with the postictal state? a. Epileptic cry b. Urinary incontinence c. Confusion d. Body rigidity

c

A client is demonstrating confusion and difficulty focusing. Which assessment findings will the nurse evaluate as supporting a diagnosis of delirium rather than dementia? Select all that apply. a. The client does not recognize her daughter. b. The client does not recognize that she is confused. c. The confusion cleared when the client is re-hydrated. d. The client's mentation was clear yesterday. e. The client's daughter reports that her mother has been becoming increasingly confused over the last 6 months.

c, d

A client with a lower motor neuron injury due to a spinal cord injury is experiencing neurogenic paralysis of the bowel. Which actions will the nurse take to assist in relieving this patient's constipation? Select all that apply. a. Massage the abdomen from left to right. b. Administer daily tap water enemas. c. Administer stool softeners d. Establish a pattern of planned bowel evacuation e. Pour warm water over the perineum.

c, d

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that will be monitored for in this client? Select all that apply. a. Salt-wasting syndrome b. Increased ICP c. Orthostatic hypotension d. Autonomic dysreflexia e. VTE

c, d, e

A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that she is eager to "beat this disease" and looks forward to the time that she will no longer require medication. How should the nurse best respond? a. "You have a great attitude. This will likely shorten the amount of time that you need medications." b. "You can likely expect a minimum of 6 months of treatment." c. "Most people are treated until their intraocular pressure goes below 50 mm Hg." d. "In fact, glaucoma usually requires lifelong treatment with medications."

d

A client is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? a. Reposition the client in a prone position b. Implement distraction techniques c. Apply a hot pack to the client's scalp d. Administer morphine sulfate as prescribed

d

A client with Guillain--Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? a. Administer bronchodilators as prescribed b. Remind the client of the importance of deep breathing and coughing exercises c. Administer supplementary oxygen by nasal cannula d. Prepare to assist with intubation

d

A client with Parkinson disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs will be met by what method? a. Provision of a low-residue diet b. Minced foods and a fluid restriction c. Total parenteral nutrition (TPN) d. Semisolid food with thick liquids

d

A hospitalized client with impaired vision must get a picture in their mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the client's room? a. That visitors do not leave items on the bedside table b. That a commode is always available at the bedside c. That the client's slippers stay under the bed d. That all furniture remains in the same position

d

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? a. Magnetic resonance imaging (MRI) b. Computed tomography (CT) c. Electromyelography (EMG) d. Electroencephalography (EEG)

d

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? a. Have the client speak to loved ones on the phone daily b. Speak in a loud and deliberate voice to the client c. Help the client complete their sentences as needed d. Provide a board of commonly used needs and phrases

d

The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long will the nurse wait before instilling the client's second medication into the same eye? a. 1 minute b. 30 seconds c. 3 minutes d. 5 minutes

d

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? Select all that apply. a. Avoiding loud environmental noises b. Instilling antibiotic ointments on a regular basis c. Rinsing the ears with normal saline after swimming d. Use a cotton swab to clean external auditory canal e. Avoid scratching the external canal with finger nail or other objects

d, e

The nurse is providing discharge education for a client with a new diagnosis of Ménière disease. What food will the client be instructed to limit or avoid? Select all that apply. a. Red meat b. Catfish c. Frozen yogurt d. Canned sardines. e. Dill pickles

d, e